Chest Pain and the Boy Who Cried Wolf

This usually comes from a patient with prior experience in the world of cardiac illness, someone who already owns a coronary stent who now wonders about every ache and pain he feels in his chest.

This is an especially vexing issue for the patient whose recurrent symptoms turn out to be false alarms. Patients are often chastised by medical personnel and family members for ignoring the early symptoms of a heart attack, but when they come back to the ER for vague aches and pains that turn out to be noncardiac, they feel like the little boy who cried wolf.

It seems like a normal psychological response to be more sensitive to chest symptoms after suffering a heart attack. These days when coronary disease is so common and everyone has either a friend or relative who’s had this experience, even healthy persons begin to wonder about chest pain, arm aching, jaw discomfort, and numbness.

A quick survey of online medical sites will lead you to believe that you should dial 911 for virtually any symptom above the naval and below the nostril, but common sense tells you that most pain in the thoracic cavity is not related to clogged-off arteries.

While I never think it’s wrong to call EMS when doubt exists about your symptoms, I also feel that a blanket recommendation to “come to the ER for any chest pain” is overly generalized and therefore not entirely helpful. With that in mind I decided to elicit the assistance of my partners to give their opinion on what type of symptoms warrant an emergency trip to the hospital.

I presented several scenarios to the dozen and a half members of my cardiology group and asked them to grade each based on how they would react to the symptoms (or how they would advise family members with similar symptoms) by using the following score card:

In the cardiology world this one’s a no-brainer. The combination of chest pain and loss of consciousness is extremely ominous and generally points toward sudden formation of a clot in a coronary artery. The downstream heart muscle becomes starved for oxygen and triggers a life-threatening rhythm (ventricular fibrillation) that leads to loss of consciousness. Your fainting episode is actually cardiac arrest that aborted spontaneously and will likely recur if untreated. Without exception all the cardiologists answered A on this one.

Case 2. Over a three-week period you develop chest pain with exertion that goes away at rest.

What I am describing here is classic exertional angina. Unlike case number 1 where a clot forms abruptly and occludes all flow through the artery, exertional angina arises when a blood vessel narrows to the point of impairing adequate flow to the heart only during periods of increasing demand. On angiography we typically see narrowings of 90% or greater when symptoms get to this point. Most of my partners answered D for this one, but with the caveat that the patient be seen within the week. Your doctor may send you for a stress test to verify that your symptoms are indeed cardiac. If you came to me with these symptoms I’d probably skip the stress test and schedule an angiogram within the next few days.

This is another scenario where you should simply dial 911 (at least that’s what nearly all my partners say). Like case number 1, this has a high likelihood of representing a heart attack. The nausea and sweating are triggered by stimulation of the vagus nerve—a response that is common when the right coronary artery becomes obstructed.

Case 4. Sharp chest pain with deep breathing.

Most of my colleagues chose D for this case (routine appointment) with a quarter suggesting a visit to the ER if the symptoms don’t improve in a few hours. Heart attacks are rarely associated with sharp pain alone, especially if it comes only with breathing. This so-called pleuritic chest pain is more commonly seen with either chest wall problems (muscle strains, costochondritis) or irritation of the lining of the lung. I imagine that the cardiologists who chose C are probably more concerned with pulmonary embolism than anything else.

Case 5. Shoulder pain coming on gradually over the course of hours.

We all know that heart-related pain can travel down the arm and into the jaw, but it’s somewhat unusual for isolated shoulder or arm pain to signal a coronary event. For this case the answers given were all across the spectrum: two doctors answered A and three answered E, with the rest being somewhere in between. The fact that some cardiologists recommend a 911 call and others say to ignore it simply illustrates how tough it is to provide generalized guidelines on how to react to unusual symptoms.

Case 6. Jaw pain upon awakening.

Again, isolated jaw or arm pain in the absence of other symptoms is typically not cardiac in origin. The consensus in my group was on answers C or D.

Case 7. Left back pain with tingling of the left arm for one day.

A lot of Ds and Es are among the answers from my partners on this one. There are a lot of odd symptoms that can go along with coronary blockage but back pain is a little unusual.

Brief, sharp pain is virtually never related to the heart. Most of my partners said E with a few Ds.

Case 9. Dull chest pain for a month but now with shooting pain down the left arm.

The clue with this one is the duration of pain—discomfort lasting longer than a few hours is likely noncardiac. I was once asked to see a patient who’d had steady chest pain since he was 20 years old (he was 55 when I evaluated him). Thirty-five years of symptoms makes a cardiac cause a little unlikely.

I’ll close with a couple of summary points. First, when in doubt there’s never any harm in calling 911 if you think you’re having a heart attack—no one critiques your decision and we’d rather see a false alarm than have you sit at home while your heart suffers.

Second, it’s interesting to note that the answer “B” was almost never given (“drive to ER immediately”). If you think you need to get to the ER for a suspected heart attack you’d better call 911 and let them take you. Every one of us can tell stories of patients with chest pain going into cardiac arrest in the passenger seat of the family sedan on the way to the hospital. Trust me, performing CPR while driving is even more distracting than text-messaging.

Finally, with the exception of case number one, there was no question in my survey that elicited a unanimous response and there were several that prompted answers spanning A to E. This means that even trained and experienced cardiologists will differ in their opinion when faced with a scenario with limited information.

In the end, the right answer to the question is this: start with common sense, and if there is any suspicion about a heart attack, simply call 911 and let the paramedics, ER doctors, and cardiologists sort it out.

9 Responses to Chest Pain and the Boy Who Cried Wolf

Thanks so much for the article you wrote. Although I am a health professional, I am often puzzled as to “how bad is it” in reference to chest pain. I really like the scoring system you gave, and in fact, I am printing it and putting it up on my refrigerator for my college age kids to know what to do with “old dad and mom’s” chest pain episodes. I really appreciated the simplicity and ease of use that you presented. Thanks a bunch!

A simple, common sense decision tree….loved it. Much better then the internet “symptom checker” programs. Someone clicks on the cyber man with symptoms you describe, and the cyber lightning bolt desends to tell you to get your you know what to the ER immediately.

The pain you describe should not be coming from your pacemaker. In fact, once your surgical site heals there should be no routine pain from the pacer.

I can’t say what the problem is, but in my experience people tend to sleep differently (in different positions) in the few months after getting a new pacemaker and with that change can sometimes aggravate arthritis or a nerve impingement of the vertebrae. This could feasibly produce pain in the back that is made better by movement.

The only pain of real concern after a pacemaker would be pain, swelling, redness and warmth at the implant site (suggesting infection) or sharp pain with breathing (suggesting possible perforation of the lead through the thin wall of the right heart chambers).

Based on the information you provided, I suppose I’d place your pain in the D category–set up a routine appointment with your doctor if the pain doesn’t resolve.

Thank you very much for your article on when to take chest pain seriously. I have been having periodic pain in my chest since having a pacemaker put in Dec 7 — Cannot tell if it is my heart or not. Includes pain (more like an ache) right in the center of my upper back, sometimes a similar ache in lower chest that feels more like heart burn (which I am generally not afflicted with). Strangely, the discomfort goes away when I move around or take a walk. It generally returns when I am resting, once kept me awake at night. I am also quite fatigued most of the time. I have always been active and had intended to resume my normal, active life after the implant. Are these symptoms normal 5-6 weeks after a PM implant? Are there any group A symptoms that apply specifically to people with pacemakers?
Thanks!

I’ve been having chest pain that comes on with exertion usually when I go above my target heart rate of 142, and last for up to 10 days, the symptoms are first a rapid heart rate with pain in the chest heart area and needing to break to catch my breath and let my heart get back down to a normal resting heart rate. Then for up to 7-10 days my heart (or chest area) feels like a very sore muscle (like someone punched me in the heart is the best way to describe it) and a tightness in the chest area, although rest does help alleviate this soreness but once I’m up and about it comes back. There is no coughing involved either. I have normal Cholesterol levels, and no High Blood pressure, weight is 138 lbs. I know that this is not heartburn I’ve felt that on separate occasions- like maybe 6 times a year. I’ve already had a Stress EKG (Sept ’10), Stress Echocardiogram (Oct ’10), and a Cardiac Catheterization (Jan ’11). All were normal, although the cardiologist mentioned that on the Stress Echo there was a part of the heart that the sono-grapher did not take a picture of and I suggested at the time that I have it done again to capture that “missed” portion of the heart. The cardiologist said no and that he’d rather just do the Cardiac Cath, which I post-poned several months since I decided that I’d rather continue to exercise by going to the gym 3 times a week and lower the amount of fat grams in my diet to see if that helped, but the pains returned and always once I’d go over my target heart rate, but sometimes the soreness would not occur until 2 days later. Do you think it would be worth while to insist on another Stress Echo or should I just move onto the other possibilities like a pulmonary issue.

I’m sorry to hear that you’re having such unpleasant symptoms. It sounds like you’ve done what you need to do to definitively rule out the possibility of chest pain arising from the heart. The cardiac cath is the final word on the status of the coronary arteries, and if it was normal then no further testing is necessary. Also, there is no need to repeat the stress echocardiogram since it won’t give you any new information.

I can’t say why you would have the chest pain, rapid heart rate, and shortness of breath. It could be a pulmonary issue, but I can’t think of anything that would produce the type of symptoms you describe. It might be worth your time to see a pulmonologist, but my guess is that your lungs are just fine.

My money is on some type of chest wall source for your symptoms. Perhaps costochondritis or something similar (see: http://blogalegent.com/Cardiology-Noncardiac-Chest-Pain). The challenging thing is that you may never figure out what it is and just have to be satisfied with knowing that it’s nothing deadly.

Im a 21 year old and have been having chest pain its sometimes sharp just under my left breast and lasts about 1 minute and other times its in the centre of my chest and it feels really uncomfortable and like ive been hit there with alot of pressure im really worried becauseim scared im going to have a heart attack even tho im so young any ideas what could be causing this pain.